Preventing physician suicide

In 2004, a medical resident at Oregon Health and Science University (OHSU) in Portland,
Ore., died by suicide. In the ensuing months, resident and faculty leaders looked
at what support systems were in place to help trainees get through several years marked
by overwhelming pressure, and they found that there were some obstacles to accessing
assistance.

Photo by Thinkstock.

That same year, OHSU created a comprehensive wellness and suicide prevention program
that now offers confidential, onsite care to residents, fellows, and full-time faculty.
The Resident and Faculty Wellness Program, which serves about 23% of residents and
8% of faculty, is free for users, does not bill insurance, and stands completely separate
from the institution's electronic health record (EHR) system—reducing physicians'
concerns about confidentiality.

“We looked at the research about why physicians don't seek treatment and found
that the stigma surrounding mental health treatment was one of their biggest concerns,”
said Sydney Ey, PhD, professor of psychiatry at OHSU and associate director of the
wellness program. “In addition, residents have limited time to go offsite and
get care, so we created a program that's both easy to access and confidential.”

A 2013 study that examined postmortem toxicology data on suicide victims from the U.S. National Violent Death Reporting System found that physicians were more
likely than nonphysicians to have high levels of antipsychotics, benzodiazepines,
and barbiturates in their blood, but not antidepressants, suggesting that many physician
in distress do not seek treatment. The authors also reported that job stress was more
likely to be a suicide risk factor for physicians than the general population.

“Physicians are more likely than others to see their job as integral to their
identity,” said the study's lead author Katherine Gold, MD, MSW, a mental health
researcher and assistant professor of family medicine and obstetrics and gynecology
at the University of Michigan in Ann Arbor. “If something happens to threaten
that identity, such as a mistake or a patient dying, they could be at risk for depression
or suicidal ideation.”

“Our study raises an alarming concern that the rate of suicide rises as physicians
age and rises to levels that are significantly greater than both the general population
and other professionals,” said the study's lead author, Thomas Nasca, MD, MACP,
CEO of the Accreditation Council for Graduate Medical Education and professor of medicine
and molecular physiology at Thomas Jefferson University in Philadelphia. “With
the rates of burnout increasing, it's crucial that hospitals create an environment
where physicians can easily and confidentially receive appropriate counseling and
support.”

While most medical students begin their education psychologically healthy, by their
third year and into residency, up to one-third are clinically depressed, more than half describe burnout symptoms, and between 6% and 12% report suicidal ideation, according to a study led by Dr.
Ey and published in the Dec. 1, 2016, Journal of Graduate Medical Education. Despite having access to high-quality care and health insurance coverage, relatively
few medical students and residents seek treatment.

Physicians are hard-wired as helpers and problem solvers and often have difficulty
accepting that they might not be able to cope with difficult situations on their own,
noted Christine Moutier, MD, chief medical officer for the American Foundation for
Suicide Prevention (AFSP) in New York City.

“Compared with the general population, physicians tend to be perfectionists
and achievement-oriented, with an exaggerated sense of responsibility and guilt,”
she said. “Those traits are absolutely counter to getting help for oneself
and knowing how to prevent a crisis.”

Historically, the requirements surrounding state licensing have presented a significant
barrier to disclosing mental health problems or seeking treatment, said Dr. Gold.
Evidence of previous diagnoses—even for very treatable conditions like depression
or anxiety—can prompt requests for documentation of proof of fitness for practice
or requests to appear before a state board of examiners, among other consequences.

Dr. Gold and colleagues recently examined whether such requirements influence female
physicians' decisions about seeking help or treatment. For the study, published in General Hospital Psychiatry in 2016, they administered an online survey to a Facebook group made up of female
physicians who were also mothers. They found that half of respondents had prior diagnoses or treatment of mental illnesses since medical school but that only 6% reported the information to their state boards.

“There is a general perception, partially rooted in truth, that it can be dangerous
to reveal that you've had a mental illness,” said Dr. Gold. “That's
particularly worrisome for women physicians, who have higher rates of suicide than
their male counterparts and women in the general population.”

The findings also raise important questions about how state boards assess mental versus
physical health and the ethics of requiring physicians to disclose past diagnoses
or current conditions that are well controlled with treatment and have no obvious
impact on practice, she said. Besides potentially violating the Americans with Disabilities
Act, questions not related to current impairment have no clear relationship to protecting
patient safety.

“In the past, if a physician disclosed that they sought treatment for substance
abuse or even depression it wouldn't have been uncommon for a state board to demand
access to their entire health history and to communicate with their psychiatrist—which
would never have been done for a nonpsychiatric condition,” said Dr. Moutier.
“That's been changing, but the majority of states still are not doing this
in the most progressive way.”

Reforms may be in sight, however. In 2016, the American Medical Association's Council
on Medical Education approved a policy recommending that state medical boards refrain
from asking about history of mental illness and substance abuse. In addition, the
Federation of State Medical Boards Workgroup on Physician Wellness and Burnout is
discussing ways to reduce the stigma associated with seeking help.

Strategies for prevention

Individual hospitals can help prevent physician suicide by creating a culture that
destigmatizes mental health changes and treatment, said Dr. Moutier. Targeted educational
campaigns should cover things like burnout, depression, and addiction and raise awareness
about their prevalence in the medical community.

Procedural or programmatic initiatives should be implemented in parallel with an educational
campaign, she said. “Just telling people to get treatment does nothing—you
have to engage them in the topic.”

For example, the Healer Education Assessment and Referral program or HEAR—co-developed
and led by Dr. Moutier at UCSD—pairs an educational campaign with a free confidential
assessment by a counselor and advice on how and where to seek treatment. Over the
past nine years, HEAR has referred 320 practicing physicians and residents to mental
health treatment, said Dr. Moutier.

Hospitals can take also practical steps to help people work more efficiently and increase
job satisfaction, said Dr. Ey. Relatively simple changes can be meaningful, such as
ensuring that clinicians have ready access to food and water or providing quiet workspaces
with natural light where people can focus.

To truly change the culture around mental health care, hospitals must prioritize workforce
well-being, said Dr. Ey. That means implementing systemic changes that allow physicians
time for self-care, including regular exercise and adequate sleep.

In order to do that, hospitals must commit resources to removing some of the time-consuming
administrative tasks that detract from physicians' job satisfaction, said Dr. Nasca.

“Administrative demands weigh heavily on physicians and keep them away from
the bedside, which is the element of their professional lives that invigorates them,”
he said. “Physicians are motivated by the urge to help others, and when they
are inhibited from doing that, it detracts from their sense of accomplishment and
overall sense of well-being.”

Physicians are particularly vulnerable to falling into depression following a tragic
event or clinical error, noted Dr. Ey. Peer support can help them make it through
painful situations and encourage them to seek professional help if needed.

“One of most devastating things that can happen to a physician is an adverse
event with a patient, and they may be discouraged from talking about it for legal
reasons,” she said. “Institutions need to be proactive with peer support
programs, and individuals need to reach out to peers when they have a rough outcome.”

Several aspects of modern health care have weakened the sense of camaraderie on workforce
teams, added Dr. Nasca. EHRs—while more convenient and efficient than manual
systems—have reduced the need for face-to-face meetings, and an increasingly
fast-paced work environment with higher productivity expectations has led many physicians
to eat on the run, for example, instead of meeting colleagues in the hospital cafeteria.

“It's important for physicians to be observant of their colleagues and watch
for signs of someone who may be slipping into clinical depression,” said Dr.
Nasca. “Everyone should know what support systems and interventions are available
in their own institutions.”

Janet Colwell is a freelance writer in West Hartford, Conn.

Steps to prevent suicide

Leaders of hospitalist programs can take a number of steps to combat the risk of suicide
among their colleagues, according to Susan Thompson Hingle, MD, MACP, current Chair
of the ACP Board of Regents and a professor of medicine at Southern Illinois University
in Springfield, Ill.

She offered four recommendations:

Talk about the risk factors and warning signs for suicide, getting rid of the culture
of silence. Risk factors can range from relationship problems to being named a defendant in a
lawsuit. Warning signs can include increasing use of alcohol or drugs; acting anxious,
agitated, or reckless; sleeping too little or too much; withdrawing from others; displaying
rage or extreme mood swings; or giving away possessions. Suicidal people may also
talk about being a burden to others or feeling trapped, hopeless, or purposeless.

Destigmatize seeking help. One easy step is to encourage colleagues to take time off for vacation and sick leave.

Make it easy to find confidential help. Be sure to post referral lists for resources inside and outside the organization in
a highly visible location that does not require a password, and assure users that
there is no tracing of page visits or downloads. Ensure that the systems are truly
confidential.

Create a support system for physicians and create a shared responsibility mindset. Support could include simply reducing a physician's patient caseload and offering
regular screenings for depression. Support groups for physicians who have been sued,
those who have lost patients, or those who are burned out may also help.

“We need to take shared responsibility for our colleagues, and if we see any
warning signs, we need to talk with them and try to get them to seek help,”
said Dr. Hingle. “Even though physicians are smart and strong, we above all
are human beings. All human beings need to be cared for.”

The American Foundation for Suicide Prevention, Mayo Clinic, and ACGME offer a toolkit to help hospitals develop a plan of action following a suicide within a physician residency or fellowship
program, as well as a brief video promoting suicide prevention for medical trainees.

The American Medical Association's Steps Forward module is aimed at identifying at-risk physicians and facilitating access to care.

ACP Hospitalist provides news and information for hospitalists, covering the major issues in the field. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.